The American journal of orthopedics
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Review Case Reports
Local infiltration of liposome bupivacaine in foot and ankle surgery: case-based reviews.
Foot and ankle surgical procedures, ranging from simple procedures, such as bunionectomy and correction of hammer toe, to more complex surgery, such as ankle fusion and ankle replacement, are extremely painful. Moreover, there is increasing interest in performing these procedures in an outpatient setting. Nerve blocks are extensively used in foot and ankle surgery, and commonly used techniques include sciatic nerve block with saphenous nerve augmentation; ankle block; and local, digital, or field block. ⋯ The first case involves ankle replacement in an active 58-year-old man with a 20-plus-year history of arthritis. The second case involves a young woman undergoing surgery for a talar neck fracture-dislocation with an open injury, dislocated subtalar joint, avascular talus, and considerable deformity. Both patients reported excellent control of postsurgical pain.
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Total knee and hip replacement surgeries are highly invasive, and a significant level of postoperative pain is commonplace in patients undergoing these procedures. It is now known that postoperative pain can affect hospital stay, patient satisfaction, postsurgical rehabilitation, and a range of other clinical and administrative outcomes. The need for a multimodal approach to the control of postoperative pain, using combinations of agents that have synergistic effects, is now widely accepted. ⋯ EXPAREL® (bupivacaine liposome injectable suspension) is an extended-release anesthetic that is approved by the US Food and Drug Administration for single-dose injection into the surgical site to produce postsurgical analgesia. Several phase 2 and phase 3 studies across a range of surgical procedures have demonstrated that the inclusion of EXPAREL® in the multimodal regimen can significantly reduce both pain scores (including cumulative pain scores at 24 hours) and opioid consumption, as well as resulting in delayed time to the first use of opioids and more opioid-free patients at 72 hours. Multimodal regimens that include EXPAREL® may have important benefits in total joint arthroplasty.
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The emergence of procedure-specific multimodal pain management regimens that provide effective control of postoperative pain, while markedly reducing the amount of opioid medication required, has been one of the most important advances in hip and knee replacement in recent years. When peripheral nerve blockade first became widely available for inclusion in multimodal regimens, it was viewed as a revolution in the management of postoperative pain. This approach, however, is costly and has some important limitations, including an increased incidence of falls. ⋯ EXPAREL® offers some important clinical and administrative benefits over nerve blocks. Preliminary data from a pilot study comparing the relative effectiveness of EXPAREL® versus sciatic nerve blockade has shown a noticeable reduction in average pain scores at rest with EXPAREL® following both hip and knee arthroplasty, as well as a reduction in the 6- to 12-hour pain score following hip arthroplasty. There was also a significant reduction in opioid use with EXPAREL®, as well as a $411 reduction in the cost of total knee arthroplasty and a $348 reduction in the cost of total hip arthroplasty.
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Comparative Study
A biomechanical comparison of superior and anterior positioning of precontoured plates for midshaft clavicle fractures.
With recent studies suggesting improved outcomes in displaced midshaft clavicle fractures treated with open reduction and internal fixation, debate has increased over the preferred plate positioning. Biomechanical studies have yielded conflicting results and have been limited by the almost exclusive use of a simple transverse fracture model. We conducted a study to biomechanically compare superior and anterior plate positioning for clinically relevant midshaft clavicle fracture patterns. ⋯ Results showed that, for all fracture patterns, more construct stiffness was achieved in axial compression and torsion (except for the oblique fracture pattern in clockwise torsion) with a superior plate, whereas more construct stiffness was achieved in cantilever bending with an anterior plate. Oblique fractures were significantly stiffer than bending wedge and complex comminuted fractures. Given the unknown relative importance of loading conditions, absolute recommendations for either superior or anterior plates cannot be made.
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Comparative Study
Acute achilles tendon ruptures: a comparison of minimally invasive and open approach repairs followed by early rehabilitation.
We retrospectively compared the outcomes of early functional weight-bearing after use of 2 different approaches (minimally invasive, standard) for surgical repair of the Achilles tendon. We reviewed the cases of 63 consecutive patients who underwent repair of an acute closed Achilles tendon rupture and had follow-up of at least 6 months. Of these 63 patients, 33 were treated with a minimally invasive posterolateral approach (minimal group), and 30 were treated with a standard posteromedial approach (standard group). ⋯ At final follow-up, the groups did not differ in their functional outcomes (ability to perform a single heel raise, American Orthopaedic Foot and Ankle Society scores). Used after a minimally invasive posterolateral or standard posteromedial approach, early functional weightbearing is an effective and safe method for treating acute ruptures of the Achilles tendon, and it has a lower rate of soft-tissue complications. A standard posteromedial approach has a higher rate of wound complications, and a minimally invasive posterolateral approach has a higher rate of sural nerve injury.